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An evaluation of the effectiveness of nutrition advisers in three rural areas of Northern Province
R Ladzani, MNutr
N P Steyn, PhD
Department of Human Nutrition, University of the North, Sovenga, Northern Province
J H Nel, PhD
Research Administration, University of the North, Sovenga, Northern Province

S A J Clin Nutr 2000 August Vol. 13 No 3.

Objective
To evaluate the efficacy of a nutrition education intervention programme undertaken by trained local women (nutrition advisers) in rural villages in Northern Province. The programme was aimed at the caregivers of infants living in those villages.

Study design
A cross-sectional survey design undertaken in 1989 and again in 1992.

Study population
Female caregivers of infants living in three study villages (study area (SA)) and three control villages (control area (CA)) in Northern Province. Households were randomly selected. The response rate of households in the SA and CA was 70% (N = 1 040) at baseline and 84% (N = 1 263) after intervention.

Methods
A baseline study was undertaken in the SA and CA in 1989. A questionnaire eliciting sociodemographic data and information on dietary practices and nutritional knowledge was developed and used in the baseline study and after intervention. A nutrition education programme was undertaken by 6 trained local women (nutrition advisers) in the SA. After 2 years the survey was repeated using the same questionnaire in both the SA and CA. The SA and CA were compared with regard to breast-feeding and infant feeding practices; use of milk, brown bread, legumes and nuts; and use of school lunch boxes by older children.

Results
The percentage of women who initiated breast-feeding on the day of birth improved significantly in the SA from 60% to 90%. The frequency of feeding infants at 6 months improved significantly in the SA (P < 0.01). The introduction of solid foods to infants on the first day of life decreased from 26.5% to 6.3% in the SA. There were no significant differences in the SA only with regard to use of milk, brown bread, legumes, nuts, and school lunch boxes. However, some positive findings were a greater increase in the use of these items in the SA compared with the CA.

Conclusion
A nutrition education programme undertaken by trained local women can significantly improve breast-feeding and infant feeding practices in rural areas.

S Afr Med J 2000; 90: 811-816

Nutrition educators are primarily concerned with helping people to adopt dietary practices that promote long-term health.1 In most developing countries the majority of the population, especially in rural areas, do not receive any nutritional advice.2 Nutritional knowledge plays an important role in nutrition education because one assumption underlying nutrition information is that increasing a person's nutritional knowledge brings about desired changes in their food-related attitudes and behaviour.3 According to Walker et al.,4 an increase in such knowledge can play a significant role in improving infant feeding practices, hopefully leading to a decrease in malnutrition. Glatthaar and Bac5 have also emphasised the importance of nutrition education as part of an integrated programme of health services.

Women are generally responsible for food production and food preparation in developing countries.6 Programmes aimed at improving household food security should therefore target women. A health facility-based nutrition programme is intended to be an integral part of the primary health care package of the Directorate of Nutrition, with the purpose of addressing the major problems of undernutrition and micronutrient deficiencies.7 Essential elements of the programme include growth monitoring and promotion, and nutrition education for caregivers and pregnant and lactating women. To date, however, there is little clarity regarding by whom, and how, the nutrition education component will be implemented.

Very little research has been published on the use of trained non-professionals (nutrition advisers) as change agents in nutritional practices. In the USA nutrition advisers were employed by the Expanded Food and Nutrition Education Programme to effect change in dietary practices.8 Their results indicated that people with limited education can be trained effectively to acquire education skills. It was also found that these advisers were better able to communicate with families and to bridge the socio-economic gap than professionals. Bowering et al.9 found that nutrition advisers were able to improve the knowledge of infant feeding practices of mothers from low-income families in East Harlem. Similar findings have been reported in the Tamil Nadu Integrated Nutrition Programme10 and the Nutrition and Primary Health Care Programme in Thailand.11

In South Africa, nutrition education is mainly undertaken by health professionals such as nurses and dietitians. Only one study evaluated the efficacy of using non-professionals in a nutrition education intervention programme aimed at lower socio-economic communities.12 Results of this study indicated that knowledge of most aspects of nutrition improved in the study areas. There was also a general improvement in dietary practices.

The objective of the present study was to evaluate the efficacy of a nutrition education intervention programme undertaken by trained local women in rural villages in Northern Province and aimed at the caregivers of infants living in those villages.

Methods

Study population
The Director of Health Services in Northern Province was consulted to identify areas that needed nutrition intervention. Mamotintane, Segopje and Ga-Mothapo were selected for practical reasons because of their close proximity to the University of the North. Three neighbouring areas, namely Moduane, Ga-Mothiba and Laastehoop, were selected as control areas. The study design included a study area (SA) that received nutrition education intervention, and a control area (CA) that did not. The study and control areas were regarded as being similar in that they are both rural villages lying approximately 30 - 50 km from Pietersburg. Geographically they are similar in terms of soil type and climate. All the villages have untarred roads and communal taps or boreholes, and few people have electricity.

A baseline study was conducted in 1989, followed by a nutrition education intervention programme from January 1990 to December 1992.

Baseline study
A baseline study was conducted in all six villages in order to obtain information about dietary practices of the inhabitants. A random sample of 250 households was drawn from each village. This was done by drawing the address of every sixth clinic card from the six clinics serving these villages. Three houses closest to the selected one were also included in the sample in order to include households that might not visit the clinic. This method of random sampling was used because the villages included in the study have houses arranged in a scattered manner and there are few conventional roads, making conventional sampling by house number difficult.

A questionnaire was developed to evaluate the nutrition education programme. This questionnaire included questions on sociodemographic information, dietary practices and nutritional knowledge of residents in the study population. The questionnaire was pre-tested on 100 households in Segopje that had not been included in the sample. Six local women were employed and trained to fill in the pre-tested questionnaire during the baseline study and after intervention. They also received training and acted as nutrition advisers during the intervention programme.

Nutrition intervention programme
The six nutrition advisers received intensive and ongoing nutrition training that included the following topics: breast-feeding, infant feeding, budget meals, general nutritional guidelines, and methods of doing nutrition education. Two nutrition advisers were stationed at each clinic in each of the three villages included in the study areas. Over the 2-year intervention programme these advisers undertook ongoing nutrition education. This included individual and group talks to local women, dietary advice to mothers of underweight infants, home visits to families with underweight children, and demonstrations on vegetable gardens and economical, nutritious meals. The overall aims of the programme were to improve nutrition knowledge and dietary practices of women in the SA.

Evaluation of the programme
A follow-up survey was conducted at the end of 1992. Interviews were once again conducted in the SA and CA. The same questionnaire was used and an additional question included in order to establish the number of households visited by the nutrition advisers during the intervention programme. Systemic sampling was used again, as for the baseline study. The same households were not interviewed again in order to limit the ÔHawthorne effectÕ, i.e. positive response that is merely the result of the attention that participants receive by being re-interviewed.13

Analysis of data
The chi-square test (c2) was used to test for significance between the SA and the CA. Data on dietary practices related to breast-feeding; infant feeding; use of milk, brown bread, legumes and nuts; and use of school lunch boxes are reported here. Data on nutrition knowledge are reported elsewhere.14

Results
The response rate of households in both the SA and CA was 70% (N = 1 040) at baseline and 84% (N = 1 263) after intervention. Ninety-six per cent of respondents in the SA reported that they received advice from a nutrition dviser during the intervention period and 75% indicated that they were visited by an adviser at their homes.

Table I indicates that the percentage of women who started breast-feeding their infants on the day of birth increased from 69% to 90% in the SA. The percentage of women who did not give colostrum to their infants decreased from 26% to 7% after intervention. The difference after intervention was significant in the SA (P < 0.01). More than 80% of women breast-fed their infants for more than 6 months. The percentage of women who breast-fed for 7 - 12 months increased after intervention in the SA. In both the SA and the CA there was a large increase in the number of women breast-feeding for a period of more than 12 months.

Infant feeding practices are given in Table II. There was a significant difference between the SA and CA after intervention with regard to what infants received at 6 months. There was an increase in both groups after intervention with regard to breast-feeding together with complementary feeding at 6 months. The frequency of feeding at 6 months was significant (P < 0.01) in the SA after intervention. The introduction of complementary feeding was significant in both areas after the programme. However, it is notable that feeding solid food on the first day after birth decreased from 26.5% to 6.3% in the SA compared with 6.0% to 1.8% in the CA.

There was an increase in the use of whole milk in both areas (Table III). The use of dairy blends decreased in the SA from 7.2% to 4.6%. About 85% of households consumed brown bread (Table IV). The use of white bread decreased in both areas, even though a small percentage of households reported using white bread. There was an increase in the use of homemade brown bread in both areas after intervention.

Although there was a significant difference in both areas with regard to the use of legumes and nuts after intervention, the SA showed a greater increase in the use of dried beans and peanuts (Table V). There was a significant difference in the CA with regard to the use of school lunch boxes. In the SA (Table VI) the percentage of children taking a lunch box to school increased from 64.9% to 80.1%.

Certain breast-feeding and weaning practices are recommended.16 Exclusive breast-feeding during the first 6 months of life is most advantageous for infants.17 Too-early introduction of complementary foods is disadvantageous as it displaces breast-milk. Breast-feeding during the second year of life is still of crucial importance because of breast-milk's high nutrient density.16

In the present study there was a significant improvement in the SA with regard to breast-feeding practices. There was an increase in the number of women breast-feeding from the day of birth. Feeding from the first day implies that the infant receives colostrum, which has tremendous benefit in terms of the immune properties conferred on the infant.18 There was unfortunately little improvement with regard to the number of women breast-feeding for longer than 12 months.

Adequate complementary feeding and frequent feeding are also recommended by the Ôcare initiativeÕ.16 Growth faltering frequently arises during the weaning period owing to the fact that young children are not fed often enough to meet their energy requirements.19 Additionally, the foods they do receive are not energy-dense, consequently a long-term energy deficit occurs. This situation may arise because of the caregiver having insufficient time available and/or lack of knowledge regarding infant feeding practices.

Infant feeding practices were similar in both groups in the present study after intervention, although more positive in the SA. Both groups increased significantly in terms of giving complementary feeds and breast-milk from 6 months of age. A very positive finding was a decrease in the introduction of solid food on the first day of life in both groups. This is a common practice in Northern Province, leading to many detrimental effects on infant nutritional status.20 The SA differed significantly from the CA after intervention with regard to frequency of infant feeding, although there was also an improvement in the CA.

There were no significant differences in the SA after intervention with regard to the other practices investigated Ñ or else there were also significant differences in the CA. However, some positive improvements were noted in the SA that deserve mention. These include an increase in the use of whole milk and a decrease in the use of non-dairy products. There was an increase in the use of homemade brown bread, dried beans and peanuts and the number of children taking a lunch box to school. One possible explanation for improvements also taking place in the CA could be the declining economic situation.21 This would have resulted in more people using ÔcheaperÕ foods such as legumes and brown bread. This may also have accounted for more children taking a lunch box instead of money to school.

When one examines the findings of other studies that have evaluated the efficacy of nutrition advisers, conflicting results are noted. Wang8 found that nutrition advisers delivered misinformation together with sound information. Chase et al.22 used nutrition advisers to educate Mexican-American migrant families. Their results showed some improvement in the nutritional status of the children, although this was not statistically significant. A programme conducted in East Harlem9 found that mothersÕ knowledge of infant feeding improved but it could not be determined whether this knowledge was put into practice.

In South Africa, Glatthaar et al.23 studied the effects of nutrition advisers (trained nurses) on educating the mothers of malnourished children. They found that the behaviour of these women did not change significantly, even though their knowledge did. Conflicting results have also been reported by Walsh.12 In a follow-up survey undertaken after 2 years of nutrition education by nutrition advisers involving families of low socio-economic status, the percentage of underweight children decreased; however, nearly all the children were found to be stunted.

The results of the present study and findings of similar studies raise controversial issues, the most important relating to the cost and benefits of such programmes. Most of the studies that have used non-professionals to do nutrition education have conducted such programmes for relatively short periods of 1 - 2 years, and have evaluated direct outcomes such as nutrition knowledge and dietary practices. There are few data on long-term outcomes and changes in related behaviours in communities that have been subjected to such programmes. Consequently it is difficult to make recommendations on using non-professionals to improve nutritional status of vulnerable groups. We do, however, recommend that the Directorate of Nutrition and non-governmental organisations investigate the possibility of introducing one or two such programmes on a long-term basis in order to evaluate both efficacy and cost effectiveness.

We gratefully acknowledge Mrs M Phoshoko, Mrs F Mothapo and Mrs W Monyepao for conducting the interviews at the homes in the study areas described. Our thanks also to all the women in the villages who participated in the study. The study was funded by the University of the North and by GD Searle (Pty) Ltd.

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Reprinted from the South African Medical Journal (2000; 90: 811-816).